Consent for Treatment Under Conscious Sedation

1. Conscious sedation will involve the placement of a cannula and the use of midazolam. I understand that, additionally, the corresponding procedure will use local anaesthetics.
2. I confirm that the treatment has been explained to me by the dentists involved, that I have had the opportunity to ask questions, and that I am aware that the procedure is in my best interest.
3. I have received advice and indications to follow before and after the treatment.
4. I agree with the treatment proposed by the Doctor, the use of conscious sedation and local anaesthetic.
5. I understand I may withdraw my consent at any time.
6. I understand that there may be a slight variation in treatment during sedation. As the treatment will be in my best interests, I agree to this variation, as I will not be able to agree to it whilst under the influence of the sedatives.
7. I understand that cancellation charges may apply:
• 50% of the sedation price will apply for cancellations within the last seven days and more than 48 hrs before the appointment.
• 100% of the sedation price will apply if the treatment is not undertaken on the day of the appointment or is cancelled within the last 48 hours.